Cases & Commentaries

Emergency Error

Spotlight Case
Commentary By Nicholas Symons, MBChB, MSc

Case Objectives

  • State that emergency surgery is high risk and has high mortality.
  • Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of error and patient harm.
  • Understand that clinical experience and seniority may reduce the risk of errors associated with emergency surgery.
  • Describe how variability in processes of care can increase the risk to patients undergoing emergency surgery.
  • List simple interventions to reduce the risk in emergency surgery including checklists, clear job descriptions, and Plan-Do-Study-Act cycles.

The Case

An 81-year-old woman with a history of pancreatitis presented with the acute onset of abdominal pain, nausea, and vomiting. On presentation, she was in distress due to severe abdominal pain. She was hypotensive and tachycardic. Based on the exam and initial imaging, there was concern for small bowel obstruction.

The decision was made to take the patient to emergency laparotomy. At the time of induction, she was given fentanyl, etomidate, and rocuronium. Almost immediately, her blood pressure dropped to 60/30 mm Hg. She was rapidly intubated, but her hypotension persisted despite epinephrine. Her heart rate slowed, and she ultimately developed asystole. Cardiopulmonary resuscitation was initiated. She received advanced cardiac life support for 10 minutes. She ultimately regained a pulse but required high doses of vasopressors to maintain her blood pressure. The operation was cancelled and she was taken to the intensive care unit. Over the next 12 hours she had progressive multi-organ system failure, and she died the following morning.

The hospital's case review committee felt the patient likely had severe acute pancreatitis and not a small bowel obstruction. The committee's judgment was that this represented a diagnostic error and that this was a preventable death (because surgery would not have been indicated in the management of her pancreatitis). The case raised many questions about the safety of and errors associated with emergency surgery.

The Commentary

Emergency general surgery is common and has significantly greater morbidity and mortality than elective surgery. Emergency surgery makes up around 50% of the general surgery workload but accounts for 80%–90% of all deaths.(1) This case describes an emergency laparotomy—a term for surgery performed to explore the abdominal cavity that may include additional procedures, such as bowel resection, formation of a stoma, or treatment of blocked or ruptured blood vessels. Patients undergoing emergency laparotomy form the highest risk group of all emergency surgical admissions; these patients have a 30-day mortality of about 15%.(2,3) Mortality is even higher in older patients like the woman in this case.(4-6) Patients undergoing emergent procedures are often elderly and have more comorbidities than those having elective surgery. In addition, emergency surgical patients are frequently acutely unwell before the operation begins. Patients requiring emergency surgery often have sepsis and renal or respiratory failure as a result of their underlying surgical condition. These factors combine to make emergency laparotomy one of the highest risk procedures performed in hospitals.

Although direct comparisons are challenging because of the diverse presentations of patients undergoing emergency laparotomy, there is increasing evidence of variability in patient outcomes between institutions. A recent study by the United Kingdom emergency laparotomy network demonstrated large differences between hospitals in mortality for emergency laparotomy.(2) UK administrative data also suggests wide variation in outcomes for emergency general surgical admissions between institutions, where 30-day mortality varies from 9.2% to 18.2%.(7) In addition, the National Surgical Quality Improvement Program (NSQIP) database (including more than 470,000 procedures at 198 hospitals over a 4-year period) suggests that in United States hospitals there is little correlation between elective and emergency surgery outcomes; hospitals with low mortality in elective operations may have high mortality in emergency surgeries.(8) Institutions also perform quite differently for emergency cholecystectomy compared with emergency colectomy and appendectomy.(5) This variability in outcomes suggests that many hospitals are underperforming and that outcomes could be significantly improved by raising all hospitals to the level of the best performers.

Variability in outcomes is likely to reflect variable processes of care. The UK emergency laparotomy network study identified variability in the use of postoperative critical care facilities and the seniority of surgeons and anesthesiologists involved in high-risk cases.(2) Administrative data from the UK has also shown that increased provision of high dependency and intensive care beds is associated with reduced mortality for emergency general surgical admissions.(7) High-dependency care is an intermediate step between ward and intensive care, involving higher levels of monitoring and nursing care but without anesthesia and ventilation. Institutions that perform greater numbers of imaging investigations (e.g., ultrasound and computed tomography [CT] scans) and those that perform fewer surgeries for high-risk general surgical admissions also seem to perform better.(7) These studies all suggest that having the right infrastructure in place, in terms of both staff and facilities, may improve emergency laparotomy outcomes.

Although having suitable infrastructure in place is important, the process of care for emergency surgical patients is also vital. As in this case, patients are frequently quite ill on presentation to the hospital, which makes rapid assessment, diagnosis, and treatment crucial. Unfortunately, in patients who present critically ill, these aspects of care are often performed poorly, which can lead to patient harm. Several studies have demonstrated very poor adherence to basic clinical and organizational processes such as administration of fluids, oxygen, and antibiotics; prescription of thromboembolism prophylaxis; and observation of patients' vital signs.(9-11) Omission of basic care processes is also associated with increased numbers of adverse events (9,10), leading to patient harm and prolonging hospital stays.

Little evidence exists regarding diagnosis and decision making for emergency general surgery, but as seen in this case, it is an area in which errors are likely quite common. The rise in CT scan and ultrasound usage has reduced the numbers of emergency surgeries performed and allowed greater use of non-operative treatment in cases of small bowel obstruction, pancreatitis, and diverticulitis. CT scanning can also help to identify those patients whose diagnosis, when considered in the context of their age and comorbidities, can be deemed to be not survivable. Deciding that a patient is unlikely to survive a large surgical procedure can allow palliative treatment to be considered as an alternative to surgery.(3) Unlike some patients who have experienced major trauma, the overwhelming majority of emergency general surgery patients are stable enough to undergo a CT scan to help define the diagnosis and surgical approach. Differentiating between, in this case, pancreatitis and small bowel obstruction due to another cause is usually possible. (I would speculate that in this case, the localized ileus that may be associated with severe pancreatitis led to the incorrect diagnosis of bowel obstruction. These two diagnoses would look identical on a plain abdominal radiograph.) Other useful information such as the presence of malignancy, perforation of the intestine, or the site of bowel obstruction can also be obtained from CT scanning.

Decisions about how, when, and whether to operate emergently are complex and based largely on experience. More senior surgeons appear to have a greater degree of certainty when assessing a patient's likely outcome and would operate less frequently than junior colleagues when presented with the same scenarios.(12) These findings underpin the need for senior surgeons and anesthesiologists to be involved at all stages of care for the sickest emergency surgical patients.

Increasing evidence supports interventions that improve the reliability of care processes for emergency general surgical patients. Improvements have been directed at the admission of patients, ward-based care, and the operating room environment. The intervention with the best evidence for efficacy is undoubtedly the checklist. The World Health Organization (WHO) perioperative checklist (Figure) is now in wide use and has been shown to be equally as effective in emergency surgery as it is in elective surgery.(13,14) Notably, the checklist highlights anesthetic or surgical concerns about the surgery to be undertaken and, in the case study above, may have increased awareness of the risk of sudden deterioration of this patient's condition on induction of anesthesia.

In terms of other types of interventions, one study found that informing medical staff that their performance was being observed had little effect, but issuing staff a job description highlighting what was expected from their role resulted in a significant improvement in process reliability during the admission of emergency general surgery patients.(10) "Lean" interventions and Plan-Do-Study-Act cycles have also been used to improve ward and admission care for emergency surgical patients with some effect.(15) Finally, another study extended the checklist paradigm to pre- and postoperative ward care and noted dramatic reductions in mortality in elective surgery; this process has not yet been tested for emergency admissions.(16)

Emergency laparotomy results in a high rate of postoperative complications, which are the most frequent cause of death for these patients.(17) Preventing these complications and recognizing and treating them early and aggressively is likely to explain much of the difference between the best performing and worst performing hospitals.(18,19) High quality and reliable processes of care in the postoperative period are likely the key to avoiding failure to rescue.

Emergency general surgery, and emergency laparotomy in particular, has high mortality and is prone to errors and adverse events. There is significant variability in the quality of care and outcomes between institutions. These findings suggest that this area of medicine offers a great opportunity for quality improvement. An emphasis on highly reliable process of care before, during, and after surgery, as well as the involvement of senior clinicians in decision making, are likely to produce the greatest benefit in patient outcomes.

Take-Home Points

  • Emergency surgery is common and carries significantly higher risk than elective surgery.
  • Emergency laparotomy is particularly high risk and carries a 30-day mortality of about 15%; mortality is significantly higher in elderly patients.
  • Diagnosis and decision making for these patients can be challenging. Senior physicians are likely to be able to do this more reliably than those with less experience.
  • Basic processes of care for these patients are frequently incomplete or omitted. Utilization of simple interventions such as checklists, formal job descriptions, and Plan-Do-Study-Act cycles can improve the reliability of care.

Nicholas Symons, MBChB, MSc

Honorary Clinical Research Fellow

Centre for Patient Safety and Service Quality

Imperial College London

Faculty Disclosure: Dr. Symons has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, the commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

1. The Royal College of Surgeons of England. Emergency surgery: standards for unscheduled surgical care. February 2011. [Available at]

2. Saunders DI, Murray D, Pichel AC, Varley S, Peden CJ; UK Emergency Laparotomy Network. Variations in mortality after emergency laparotomy: the first report of the UK Emergency Laparotomy Network. Br J Anaesth. 2012;109:368-375. [go to PubMed]

3. Al-Temimi MH, Griffee M, Enniss TM, et al. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg. 2012;215:503-511. [go to PubMed]

4. Cook TM, Day CJE. Hospital mortality after urgent and emergency laparotomy in patients aged 65 yr and over. Risk and prediction of risk using multiple logistic regression analysis. Br J Anaesth. 1998;80:776-781. [go to PubMed]

5. Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Variation in quality of care after emergency general surgery procedures in the elderly. J Am Coll Surg. 2011;212:1039-1048. [go to PubMed]

6. Mamidanna R, Eid-Arimoku L, Almoudaris AM, et al. Poor 1-year survival in elderly patients undergoing nonelective colorectal resection. Dis Colon Rectum. 2012;55:788-796. [go to PubMed]

7. Symons NR, Moorthy K, Almoudaris AM, Bottle A, Aylin P, Faiz O. Mortality in high risk emergency general surgical admissions: the implications of resource availability in the NHS. Br J Surg. 2013. In press.

8. Ingraham AM, Cohen ME, Raval MV, Ko CY, Nathens AB. Comparison of hospital performance in emergency versus elective general surgery operations at 198 hospitals. J Am Coll Surg. 2011;212:20-28.e21. [go to PubMed]

9. Kreckler S, Catchpole KR, New SJ, Handa A, McCulloch PG. Quality and safety on an acute surgical ward: an exploratory cohort study of process and outcome. Ann Surg. 2009;250:1035-1040. [go to PubMed]

10. Stevenson KS, Gibson SC, MacDonald D, et al. Measurement of process as quality control in the management of acute surgical emergencies. Br J Surg. 2007;94:376-381. [go to PubMed]

11. Symons NR, Moorthy K, Vincent C; London Surgical Research Group. Omissions in the process of care for emergency general surgical admissions. Br J Surg. 2013. In press.

12. Szatmary P, Arora S, Sevdalis N. To operate or not to operate? A multi-method analysis of decision-making in emergency surgery. Am J Surg. 2010;200:298-304. [go to PubMed]

13. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360:491-499. [go to PubMed]

14. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA; Safe Surgery Saves Lives Investigators and Study Group. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg. 2010;251:976-980. [go to PubMed]

15. McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. Effect of a "Lean" intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. [go to PubMed]

16. de Vries EN, Prins HA, Crolla R, et al; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928-1937. [go to PubMed]

17. Iversen LH, Bülow S, Christensen IJ, Laurberg S, Harling H; Danish Colorectal Cancer Group. Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg. 2008;95:1012-1019. [go to PubMed]

18. Silber JH, Williams SV, Krakauer H, Schwartz JS. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care. 1992;30:615-629. [go to PubMed]

19. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368-1375. [go to PubMed]

20. World Health Organization. Safe Surgery Saves Lives: The Second Global Patient Safety Challenge. September 2009. [Available at]

Figure

Figure. World Health Organization Surgical Safety Checklist. Reprinted from (20) with permission from World Health Organization Press.